Managed Care Organizations, Medicare, and Medicaid

The ultimate goal of managed care organizations, Medicare, and Medicaid programs is to ensure a wide range of quality care and managed healthcare services are provided to the enrolled clients using various means to ensure medical costs are kept down. However, the programs differ in how they have been managed and the serves they offer. The essay explains the nature of both managed care plans, Medicaid and Medicare.

Part One

The managed care organization(MCO)is a group of healthcare providers that provide managed care healthcare plans. MCOs contract with an insurer or self-insured employers and therefore finance and provide medical care using a specific provider network and offers specific products and services to their clients. On the other hand, the Medicare program is a program under the federal government that offers healthcare coverage for individuals aged 65 and above years or those under 65 but living with disability despite their income, as shown in table 1. On the other hand, Medicaid is a  state and federal program that provides health coverage for individuals with a meager income.

Gatekeeping has been one of the most common features present in managed care in the United States. Over the years, it has become an effective tool in health maintenance organizations despite criticism due to the public perception that medical decisions are made based on financial considerations (Garrido et al., 2010). The gatekeeping system comprises physicians that act as the link between primary and secondary care of the patient (Liang et al., 2019). In this case, a patient is not allowed to access secondary care as the initial entry despite their wish of receiving secondary care. The gatekeeping system has been used to effectively manage the cost of healthcare by minimizing the number of interventions that are not requisite (Liang et al., 2019). Primary care is in charge of carrying out tests and diagnoses that are considerably cheaper than secondary care.

Moreover, at this stage, a physician can identify the patient who would require specialized care and where the patient can access it. This is a benefit to minimizing the overutilization of the secondary care facilities, thus reducing the cost of medical care (Liang et al., 2019). The physician also collaborates with their patient, thus identifying their needs to offer the best services and meet patient demand effectively.  This helps the country meets its individual needs and satisfy their demands since few resources are used.  This will promote social, economic, and political growth in the countries as the individuals access quality care where they access it with much ease (Michael L. Barnett et al., 2021). Since gatekeeping is service-oriented rather than profit-oriented, the physicians will be able to deliver their services fairly and win the patient’s trust, thus promoting the level of care offered by this program.

In recent years, advanced systems have been put in place to improve the services offered to improve patient care and manage and maintain data to secure it. Due to this, the physicians take money from the patient to offer them these services, making MCO business-oriented (Michael L. Barnett et al., 2021). Cases of unwanted diagnosis and checkups have been observed. The intention is that these facilities can be customized to make more money, thus increasing the rapport between the physicians and patients. If the services to be offered are money-oriented, the system will be at risk of destruction.

Part Two

Medicare can prevent the draining of its resources by reducing preventable readmissions and unnecessary complications and coming up with an incentive to provide quality care. The other alternative is reducing the price and use of high-cost drugs in pharmaceuticals. This includes banning the pay for delay agreements (CRFB, 2017). The physicians can be encouraged to go for cheaper and more effective ones.

Use of generic drugs, thus lowering copays by creating more branded ones. Medicare can also adopt a competitive bidding structure for their advantage, lowering the cost of Medicare advantage and improving the quality of care given (CRFB, 2017). Medicare can also restrict supplemental coverage, which results in overspending and greater out-of-pocket costs. By limiting the Medigap plan, it will benefit the beneficiaries and the federal government.

Part Three

Medicaid assists in providing care and financial security for low-income elderly people. Medicaid can reduce its drain of resources by reducing the complex care management and coming up with several smaller programs that improve utilization or spreading of resources. This includes reducing ED visits, hospital admission, or inpatient expenditures (Wiener et al., 2017). The other one has patient-centered medical homes, which will, in turn, reduce ED and hospital usage.  Medicaid can expand home and community-based services where the elderly group can use home care instead of being admitted to nursing home use (Wiener et al., 2017). This will reduce the number of visits in hospitals, thus reducing the cost of Medicaid.

In conclusion, the ultimate goal of MCO, Medicare, and Medicaid are to offer quality healthcare services and at the same time keep the medical cost down. If the government adopts some of the MCO systems “gatekeeping,” they may handle the burden of the budget in both Medicare and Medicaid resources convalescent.

References

CRFB. (2017). How to Reduce Medicare Spending Without Cutting Benefits. Committee for a Responsible Federal Budget. Retrieved 18 September 2021, from https://www.crfb.org/blogs/how-reduce-medicare-spending-without-cutting-benefits.

Garrido, M., Zentner, A., & Busse, R. (2010). The effects of gatekeeping: A systematic review of the literature. Scandinavian Journal Of Primary Health Care, 29(1), 28-38. https://doi.org/10.3109/02813432.2010.537015

Liang, C., Mei, J., Liang, Y., Hu, R., Li, L., & Kuang, L. (2019). The effects of gatekeeping on the quality of primary care in Guangdong Province, China: a cross-sectional study using primary care assessment tool-adult edition. BMC Family Practice, 20(1). https://doi.org/10.1186/s12875-019-0982-z

Wiener, J., Romaire, M., Thach, N., Collins, A., Kim, K., & Pan, H. et al. (2017). Strategies to Reduce Medicaid Spending: Findings from a Literature Review. KFF. Retrieved 18 September 2021, from https://www.kff.org/medicaid/issue-brief/strategies-to-reduce-medicaid-spending-findings-from-a-literature-review/view/footnotes/.